Cultural Competency Curricula in US Graduate Medical Education: A Scoping Review Open Access

In 2003, the Institute of Medicine released its call to action for cultural competency curricula to be incorporated into medical education,¹  as racial and ethnic minority groups in the United States experience worse health outcomes and report poorer satisfaction with their health care compared to non-minority patients.^2,3  Poor patient-clinician communication is associated with worse clinical outcomes across medical specialities,^4,5  and these communication deficiencies are speculated to contribute to health inequity.^6,7  Effective communication leads to improved physical and mental health,⁴  but patients of color commonly report subpar communication from their physicians.^8–11 

The Accreditation Council for Graduate Medical Education (ACGME) requires all residency programs in all specialties to include training and assessment of resident skills in caring for diverse patients.¹²  Despite this requirement, there is limited evidence that residency programs have implemented effective curricula focused on the care of diverse patient populations.¹³  In fact, up to half of graduating residents across surgical and medical specialties report receiving little or no instruction in cross-cultural care during residency, and approximately a quarter feel unprepared to identify cultural customs that impact medical care.¹⁴  As a result, the need for effective cultural dexterity training for residents has been highlighted.^15–17 

While various curricula have been proposed and implemented for medical clinicians,¹⁸  these largely focus on the medical student level.¹⁹  A review of the literature limited to residency and fellowship programs in the United States will help inform such programs as they seek to implement and scale their own curricula within the constraints of the rigorous schedules of trainees. Due to wide variability in the topic areas and delivery methods of cultural competency curricula, we performed a scoping review to explore common themes and challenges.

We followed the 5-step methodological framework described by Arksey and O'Malley²⁰ : (1) Identifying the research question; (2) Identifying relevant studies; (3) Selecting studies; (4) Data charting; and (5) Collating, summarizing, and reporting the results. This study is reported in compliance with the PRISMA-ScR checklist.

We framed our review around the question, “What is the current landscape of cultural competency curricula in US graduate medical education (GME)?” Our goal was to provide a better understanding of common methods, themes, and challenges to inform residency and fellowship programs hoping to implement or modify their own such curricula. Specifically, we investigated variables pertaining to curriculum focus, methods of implementation, duration of interventions, and methods of assessment and evaluation.

We iteratively developed search criteria with guidance from an experienced medical librarian (P.B.) and edited with the assistance of 2 authors (R.A., E.R.), with the goal of identifying educational curricula or training programs focused on concepts of cultural competency, cultural diversity, and health care disparities published in English from January 2004 through April 2020. These dates of interest were selected based on the previously mentioned 2003 Institute of Medicine call to action for the implementation of cultural competency curricula. For the purposes of this study, curricula/trainings must have been intended for US GME (ie, residents and fellows across any medical specialty).

Articles reporting on cultural competency curricula and training in GME were identified by searching the electronic databases MEDLINE, ERIC, and PsycINFO. Our search was structured to capture articles that included terms reflecting the concepts of cultural competence, cultural diversity, or health care disparities together with terms for education and curriculum in the context of GME and residency (specific database searches provided as online supplementary data). The search for education topics included all indexed articles published in medical education journals. Controlled vocabulary terms were included when available, and no language limits were applied. The searches were carried out on April 20, 2020, and were limited to articles published in 2004 or later.

For the first step of the review, each title/abstract was examined by 2 reviewers, one of whom was a senior reviewer. If there was agreement between those 2 reviewers, that abstract was either advanced to the second step of a full text review or excluded. If there was a disagreement between those 2 reviewers, a senior reviewer who did not initially examine the abstract reviewed it. The determination of that third reviewer decided whether the abstract advanced to step 2. Due to the large number of articles, full text review was divided among 7 reviewers. All articles advanced from the full text review were again confirmed by a senior reviewer. Data extraction was performed by the 4 senior reviewers and analysis of the extracted data was conducted by a single senior reviewer. We did not assess the quality of each study as the goal of our scoping review was to broadly map the existing literature on this topic.

The reviewers collaboratively decided upon the data points of interest based on personal experience developing and implementing a cultural competency curriculum, as well as themes noted during the full text review. These data points were authors, title, publication source, year of publication, learner population training level, resident/fellow specialty, educator population, specific area of cultural competency focus (if any), educational delivery methods, intervention schedule and/or length, intervention outcomes, method of data collection, assessment design, sample size, and results. We collected these data through Google Forms and exported them to Microsoft Excel for descriptive analysis.

We employed 2 methods of collating and summarizing the charted data. First, we performed a descriptive numerical analysis on the frequency of various data points, such as curricular topics, specialties, educational delivery methods, and others. We then developed a consensus on common and/or interesting themes that were noted during the data charting process. Themes of interest were determined through discussion of either recurrent topics across studies or topics that stood out as most likely to help inform the implementation of cultural competency curricula.

Our search yielded 1825 unique records. Full-text documents were examined for 322 of these, and ultimately 67 articles were included for analysis (Figure). Characteristics of the included studies can be seen in the Table. ^21–87  Year of publication ranged from 2004 to 2020. Sixty-one (91.0%) described curricula or programs specifically for residents. The 3 most common specialties represented were psychiatry (n=19, 28.4%), internal medicine (n=16, 23.9%), and pediatrics (n=15, 22.4%). More than half of the studies (n=39, 58.2%) utilized didactic sessions/lectures. Several studies (n=22, 32.8%) incorporated clinical or community-based experiences to complement the didactics. The shortest intervention was a 30-minute online module, and the longest interventions were lectures, electives, and mentoring programs that spanned the duration of residency training (up to 4 years). Eight studies (11.9%) used OSCEs as a method of assessment; 17 (25.4%) conducted semi-structured interviews or focus groups. With regards to evaluation design, 25 (37.3%) used a post-intervention assessment, 33 (49.3%) did a pre-/post-design, and 2 (3.0%) were randomized controlled trials. The smallest and largest sample sizes evaluated were 6 and 833, respectively. The mean number of participants was 47 if including the largest study, or 34 if excluding the largest study, which was an outlier. Only 2 studies investigated patient outcomes, both of which were self-reported patient perception or satisfaction.^42,74  Four themes of note arose for further descriptive analysis: unique interventions/curricula, retention of learning, trainee evaluation of curricula, and resources required for curriculum implementation.

While the vast majority of included studies used lectures/didactics as educational methods, a few groups found innovative ways of teaching cultural competency. For example, Anand et al utilized art therapy sessions with psychiatry residents and patients to stimulate discussions on empathy, humility, curiosity, and respect.²²  While the goal of this intervention was not specifically focused on cultural competency, these themes are accepted in the literature as central tenets to providing culturally competent care, and residents reported that this experience provided a unique way to learn more about patients' cultural backgrounds. Castillo et al asked residents to perform reflective journaling on their cross-cultural experiences using a semi-structured guide.³⁰  Residents reflected on expectations/assumptions prior to these encounters, similarities and differences they noted between themselves and their patients, and what aspects of this cross-cultural care they would continue to use in their practice. Medlock et al held a lecture series on racial and ethnic minority patient care throughout the duration of a psychiatry training program, with a different topic for each class year.⁶⁰  Although the use of lectures is not unique, the intern lecture focused on the history of racism specific to the training program city. “Presenting the historical background for patients' experiences…was effective in demonstrating the experiences of institutional, interpersonal, and internal racism that contributed to the patient's [presentation].” The authors noted that this lecture topic could be readily adapted to other cities and training programs.

Three studies described issues with long-term retention of curricular concepts. Immediately following a single, 90-minute lecture on the care of transgender patients, Kidd et al found a statistically significant improvement in 4 out of 5 domains taught in the session (empathy, knowledge, comfort, and motivation for future learning) as compared to pre-intervention assessment.⁴⁸  Unfortunately, these improvements were not maintained on repeat testing 90 days later. Similarly, Harris et al assessed retention 9 months following a multicultural competence course for psychiatry residents.⁴⁰  They found that residents' awareness of their own privilege significantly declined over the time period, while other multicultural knowledge, skills, and attitudes were also lower but did not achieve significance. The authors hypothesized that residents lose awareness of these complex issues without regular discussion, and that normalizing conversations about bias and privilege may allow for better long-term retention. The longest retention analysis was performed by Anandarajah et al in their evaluation of a longitudinal spiritual care curriculum.²³  Their group interviewed family medicine residents prior to receiving the curriculum, immediately following conclusion of the curriculum, and then 8 years later as attending physicians. Many reported difficulty remembering details of their spiritual care training: “I honestly do not remember any specific aspects of the curriculum other than the idea of being comfortable with bringing it up.” Nevertheless, respondents were supportive of receiving this type of education early in their medical training, as this engrained these topics as a routine part of patient care.

In addition to evaluation of curricular efficacy, several studies sought to examine the trainee experience through qualitative methods as a way to enrich their analysis and guide future adaptations of their efforts. Some trainees commented on the role their own biases play in providing patient care: “I am more aware of power imbalances and the history of psychiatry, which makes me more reflective about my own practices.”²⁷  “…[residents] expressed a great deal of satisfaction about enjoying the exploration of their own cultural/spiritual backgrounds and how these related to patient care.”⁵¹  Some trainees struggled with how to address these issues: “…residents reported feeling overwhelmed by their increased recognition of structural influences on health. They expressed a need for practical strategies to address structural vulnerabilities in and beyond clinical settings.”⁶⁴  In addition to these reflections on curricular content, some groups sought to examine the trainee perspective on the structure and implementation in order to improve trainee buy-in and overall satisfaction. Willen et al found that trainees preferred their education to be more interactive and less lecture-based; to have judgment- and repercussion-free safe spaces to discuss their concerns and feelings; and to use real-life experiences of residents and instructors as educational tools, rather than dated or unengaging articles.⁸¹  Participants in one study cited the importance of senior residents serving as role models with regards to culturally competent behaviors, as well as institutional and leadership buy-in.⁷⁷ 

Several studies reported the resources required to implement their cultural competency initiatives, both monetary and otherwise. Noriea et al required no external funding for their health disparities curriculum and spent only $300 on meals provided to residents during didactic sessions.⁶⁵  Although financially reasonable, the time cost for curricular development and implementation was not insignificant, at a total of 120 hours and 36 hours, respectively. An even more extensive example is found in the medical Spanish immersion curriculum described by York Frasier et al.⁸⁴  Their program required notable financial and scheduling commitments, as this was a 6-day experience during which family medicine interns were provided with all lodging, meals, and curricular materials including videos, books, CDs, and 42 hours of instruction. In the discussion, the authors note that costs were reduced in subsequent years by eliminating the overnight lodging component of the experience.

Our investigation into the current state of cultural competency curricula within US residency and fellowship training programs identified 67 articles over a 15-year period. While previous studies have analyzed these curricula across a variety of health care fields,^88–90  this review focused only on residents and fellows in order to draw conclusions more specific to this population. Trainees provide a substantial amount of the direct patient care at academic medical centers, serving patients from a diverse array of backgrounds. These trainees are the future attending physician leaders in our health care system, and thus are the ideal targets of interventions aimed at creating a more equitable health care system. Optimization of cultural competency training for residents and fellows has the potential to lead to broader culture change within medicine and improve care for patients of all backgrounds. This review highlights 4 important considerations when attempting to implement cultural competency curricula, therefore providing guidance on how residency and fellowship programs may address these curricular needs.

Non-traditional methods of education, such as art therapy²²  or reflective journaling,³⁰  may serve to better engage residents and fellows. This resident engagement is critical to buy-in, and interventions that increase self-awareness of one's own implicit bias may make participation in a cultural competency curriculum more enticing.⁹¹  The use of visual art to improve general observational skills and cultural sensitivity is more common in medical student education as compared to GME.^92,93  This may be due to perceptions that residents and fellows do not have time for non-clinically focused education, or perhaps that these humanities-oriented programs are not appealing to more senior trainees. While evidence for educational efficacy of these interventions is limited, they are generally well-received by learners.^92,93  An additional benefit of these more artistic, individualistic interventions is their low cost and ability to fit into a busy trainee schedule based on personal availability. Tailoring cross-cultural curricula to specific patient populations frequently encountered by trainees may further increase buy-in. Programs developing their own curricula may be well-served by such targeted, innovative approaches, rather than more traditional lectures on broad cultural competency topics.⁶⁰ 

Our search found evidence that trainees' knowledge, skills, and self-awareness of cross-cultural issues variably declined over time frames of 90 days to 8 years.^23,40,48  The groups that studied retention mainly used a combination of large group lectures and small group discussions in their curricula. Some research groups have found that certain formats of curriculum delivery are more effective at producing retention than others, such as bolus web-based teaching⁹⁴  or interactive, case-based drills.⁹⁵  Among medical students, high-dose, low-frequency simulation with trained, invested instructors may improve long-term clinical knowledge retention.⁹⁶  For residents and fellows, cultural competency simulation may achieve sustainable mastery of skills that are broadly applicable across clinical specialties and scenarios.

It is of the utmost importance for programs to continually seek feedback in order to optimize chances for success within their trainee population. Some trainees seek a deeper understanding of their own biases and backgrounds and how these impact the outcomes of their patients.^27,51  As previously stated, they also prefer interactive curricula over lectures⁸¹  and seek practical tips for utilizing cultural competency skills in real clinical scenarios.⁶⁴  Trainees also found it important that departmental leadership and senior residents must serve as role models by visibly engaging with and supporting the lessons imparted by cultural competency curricula.⁷⁷  This last point is of particular importance in the midst of ongoing national conversations regarding race and racism in the United States. Faculty discomfort or inexperience with discussing these difficult topics limits trainees' opportunities for growth and education in these realms.⁹⁷  In order to be effective educators, faculty and leadership must first be effective and willing learners. Just as physicians are often encouraged to be “lifelong learners” with regards to clinical medicine, cultural competence is a longitudinal undertaking. As such, some have suggested that “cultural humility” is a more appropriate term, as it removes implications of an end point where one is deemed “competent.”⁹⁸ 

While not addressed by most articles included in this review, the time and costs of any educational program are important considerations, as they hold strong implications for sustainability and ability to disseminate more broadly.^65,84  Programs may reduce both time and costs of implementation by seeking out existing, peer-reviewed cultural competency curricula published online (such as MedEdPORTAL); partnering with institutional diversity, equity, and inclusion groups; or collaborating with other institutional GME programs with similar educational goals.

This review was limited to studies written in English and published in peer-reviewed journals. This potentially excludes descriptions of cultural competency curricula that are being used in practice but have not been published. The benefit of those curricula that have undergone peer review is that they tend to be highly contextual, detailed, and longitudinal, and thus attempt to address cultural competency in a systemic way. Additionally, our method of categorizing studies by topic of cultural competency focus may differ from the study authors' perspectives due to reviewer subjectivity.

This scoping review found that the literature on GME cultural competency curricula reports improved trainee satisfaction with unique curricular designs, importance of trainee evaluations, difficulty achieving knowledge retention, and consideration of program-specific resource limitations.